Prescott Animal Hospital (PAH Holdings PC) Annual Report (Arizona Corporation Commission) (2016)

mnission

STATE OF ARIZONA
COPY CORPORATION COMMISSION ATA
CORPORATION ANNUAL REPORT 05395017
& CERTIFICATE OF DISCLOSURE Nea
DUE ON OR BEFORE 3/29/2016 FILING FEE $45.00

PLEASE READ ALL INSTRUCTIONS. The following information is required by A.R.S. §§10-1622 & 10-11622 for all corporations
organized pursuant to Arizona Revised Statutes, Title 10. The Commission's authority to prescribe this form is A-R.S. §§ 10-121(A)
& 10-3121{A). YOUR REPORT MUST BE SUBMITTED ON THIS ORIGINAL FORM. Make changes or corrections where necessary.
Information for the report should reflect the current status of the corporation.

08713675
4, PRESCOTT ANIMAL HOSPITAL COMPANION ANIMAL CENTER, P.C.
FEB.19 2018 -
PRESCOTT, AZ 86305 pnzan epee eee

. 1318 IRON SPRINGS RD
ype of Corporation: PROFESSIONAL

Business Phone: _(28) 445-2190
State of Domicile: ARIZONA

Statutory Agent: MICHAEL L RUBIN
Mailing Address: 230 ANDERSON RD
City, State, Zip: PRESCOTT, AZ 85303

Statutory Agent's Street or Physical Address, (f Different.

ACC USE ONLY

if appointing a new statutory agent, the new agent MUST consent to that
appointment by a below. Note that the agent address must be in Arizon

{individual or We, (corporation or limited fability company) having been designated the new Statutory Agent,
lo hereby consent to this appointment until my removal or resignation pursuant to law.

Signature of new Statutory Agent i

Printed Name of new Statutory Agent

3. Secondary Address:

(Foreign Corporations are REQUIRED
10 complete this section).

4. Check the one category below which best describes the CHARACTER OF BUSINESS of your corporation.

NON-PROFIT CORPORATIONS
1, [™ Charitable

BUSINESS CORPORATION:
J 1. Accounting © 20. Manufacturing
7 2, Advertising F 21, Mining
& 3. Aerospace F 22. News Media
© A. Agriculture = 23. Pharmaceutical
& 5. Architecture EF 24. Publishing/Printing
6. Banking/Finance 28. Ranching/Livestock
I~ 7. Barbers/Cosmetology [ 26. Real Estate
& 8. Construction if 27. Restaurant/Bar
i 9. Contractor F 28. Retail Sales
I 10. Credit/Callection £29. Science/Research
= 11. Education £30. Sports/Sporting Events
» = 12. Engineering £31. Technology(Computers)
= 18. Eatertainment © 32. Technoiogy(General)
rope d14 Ggheral Consulting = 33. Television/Radia
. ‘15. Héalth Care Y= 34. Tourism/Convention Services
” 16. Hofel/Motet 35. Transportation

r 18. Insurance

AR:0046
Rey, 02/2016

"17. IaporVExport

36. Utilities
i 37. Veterinary Medicine/Animal Care

19. Legal Services F 38. Other

11.
. = Hospital/Health Care

. <— Agricultural

. 5 Cooperative Marketing Association
. [= Animal Husbandry

. I- Homeowner's Association

. 5 Professional, commercial

iia aa sale

e
ee

Educational
Civic
Political

AAPA AA
a

© Athletic
re Science/Research

industrial or trade association

. = Other.

Arizona Corporation Gommission
Corporations Division

08713675 PRESCOTT ANIMAL HOSPITAL COMPANION ANIMAL CENTER, P.C. page 2

5, CAPITALIZATION: (For-profit Corporations and Business Trusts are REQUIRED to complete this section.)
Business trusts must indicate the number of transferable certificates heid by trustees evidencing their beneficial interest in the trust
estate. PLEASE PRINT OR TYPE CLEARLY.

5a. Please examine the corporation’s original Articles of Incorporation for the amount of shares authorized.
Number of Shares/Certificates Authorized Class Series Within Class (if any)
100000.00 COMMON

5b. Review all corporation amendments to determine if the original number of shares has changed. Examine the corporation's
minutes for the number of shares issued.
Number of Shares/Certificates Issued Class Series Within Class (if any)
2000.00 COMMON

6. SHAREHOLDERS: (For-profit Corporations and Business Trusts are REQUIRED to complete this section.)

List shareholders holding more than 20% of any class of shares issued by the corporation, or having more than a 20% beneficial
interest in the carporation.

Name: Dr. Kenneth C Skinner Name: DR CAMERON S DOW
none [_]
Name: Dr. Bryan K Nolte Name:
7.QFFICERS PLEASE TYPE OR PRINT CLEARLY. YOU MUST LIST AT LEAST ONE.
Name: Dr Kenneth C Skinner _ Name: _Dr Bryan K Nolte
Title: PresidentiCEO Title: Vice President
Address: 783 Pepeprmint Way Address: 7685 N Deerfield Dr
Prescott, Arizona 86305 Prescott, Arizona 86503
Date taking office: 1/1/2013 Date taking office: 1/1/2003
Name: 27 Cameron S Dow Name:
Title: Vice President Title:
Address: 793 Grapevine Lane Address:
Prescott, Arizona 86305
Date taking office: 5/4/2015 Date taking office:
8. DIRECTORS PLEASE TYPE OR PRINT CLEARLY. YOU MUST LIST AT LEAST ONE.
Name: DDR CAMERSON S DOW Name: Dr Kenneth C Skinner
Address: 793 GRAPEVINE LN Address: 783 Peppermint Way

Prescott, Arizona 86305

PRESCOTT, AZ 85601

Date taking office: 05/04/2015 Date taking office: AIL1997
Name: Dr Bryan K Nolte Name:
Address: 7685 N Deerfeild Dr Address:
Prescott, Arizona 86305
Date taking office: 41/1/2000 Date taking office:
AR:0046 Arizona Corporation Commission

Rev. 02/2016 Corporations Division

Please Enter Corporation Name: PRESCOTT ANIMAL HOSPITAL COMPANION ANIMAL CENTER, P.C. File number 08713675 Page 3

9. FINANCIAL DISCLOSURE (A.R.S. §10-11622{A}{9))

Nonprofits — financial disciosure is no longer required. Cooperative marketing associations — must submit a financial statement. All othertypes
of corporations are not required to file a financial statement.

ONLY NONPROFIT CORPORATIONS MUST ANSWER TH STION:
9A. MEMBERS (A.R.S. §10-11622(A}(6)) This corporation DOES CF DOES NOT id have members.

10. CERTIFICATE OF DISCLOSURE (A.R.S. §§ 10-202(D), 10-3202(D), 10-1622(A)(8) & 10-11622(A){7))

A. Has any person who is currently an officer, director, trustee, incorporator, or who, in a Far-profit corporation, controls or holds more than
40% of the issued and outstanding common shares or 10% of any other proprietary, beneficial or membership interest in the corporation
been:

1. Convicted of a felony involving a transaction in securities, consumer fraud or antitrust in any state or federal jurisdiction within the seven year
period immediately preceding the execution of this certificate?
2. Convicted of a felony, the essential elements of which consisted of fraud, misrepresentation, theft by false pretenses or restraint of trade or
monopoly in any state or federal jurisdiction within the seven year period immediately preceding execution of this certificate?
3, Subject to an injunction, judgment, decree or permanent order of any state or federal court entered within the seven year period immediately
preceding execution of this certificate where such injunction, judgment, decree or permanent order involved the violation of.
(a) fraud or registration provisions of the secutities laws of that jurisdiction, or
(b) the consumer fraud laws of that jurisdiction, or
(c) the antitrust or restraint of trade laws of that jurisdiction?

One box must be marked: YESO no
If “YES" to A, the following information must be submitted as an attachment to this report for each person subject to one or more of the
actions stated in Items 1 through 3 above.

1. Full birth name. 5. Date and location of birth.

2. Full present name and prior names used. 6. The nature and description of each conviction or judicial

3. Present home address. action; the date and location; the court and public agency

4. Alt prior addresses for immediately preceding 7 year involved; and the file or cause number of the case.
period.

B. Has any person who is currently an officer, director, trustee, incorporator, ar who, in a For-profit corporation, controls or holds over 20% of
the issued and outstanding common shates, or 20% of any other proprietary, beneficial or membership interest in the corporation, served
in any such capacity or held a 20% interest in any other corporation on the bankruptcy or receivership of that other corporation?

One box must be marked: YESO NOG
Ht “YES” to B, the following Information must be submitted as an attachment to this report for each corporation subject to the
statement above.
(a) Name and address of each corporation and the persons involved.
(b) State(s) in which it: (i) was incorporated and (ii) transacted business.

(c) Dates of corporate operation.

11, STATEMENT OF BANKRUPTCY OR RECEIVERSHIP {(A.R.S. §§ 10-1623 & 10-11623)

A. Has the corporation filed a petition for bankruptcy or appointed a receiver? One box must be marked: YES Gi NO oh

Hf “Yes” to A, the following information must be submitted as an attachment to this report:

1. All officers, directors, trustees and major stockholders of the corporation within one year of filing the petition for bankruptcy or the
appointment of a receiver. If a major stockholder is a corporation, the statement shall list the current president, chairman of the
board of directors and major stockholders of such corporate stockholder. “Major stockholder” means a shareholder possessing or
controlling twenty per cent of the issued and outstanding shares or twenty per cent of any proprietary, beneficial or membership
interest in the corporation.

2. Whether any such person has been an officer, director, trustee or major stackholder of any other corporation within one year of the
bankruptcy or receivership of the other corporation. If so, for each such corporation give:
(a) Name and address of each corporation;
(b) States in which it (i) was incorporated and __{ii) transacted business.
(c) Dates of operation.

12. SIGNATURES: [Annual Reports must be signed and dated by at least one duly authorized officer or they will be rejected.

tdeclare, under penalty of perjury, that all corporate income tax returns required by Title 43 of the Arizona Revised Statutes have been
filed with the Arizona Department of Revenue. | further declare under penaity of perjury that | (we) have examined this report and the
certificate, including any attachments, and to the best of my (our) knowledge and belief they are true, correct and complete.

2/17/2016
iwi Date Name
Signature VA wud lELTD Signature
President/CEO and Director of Prescott Animal Hospital Title

{Signator(s) must be duly authorized corporate officer(s} fisted in section 7 of this report.)

AR:0046 Arizona Corporation Commission
Rev, 02/2016 Corparations Division

Nam __Date.

Title